Hipaa Form Authorization To Release Health Care Billing Information printable pdf download

HIPAA Form – For help finding proof in Health Net Settlement.

For Group B and Group C Claims only - Otherwise disregard this form.

If you are submitting any GROUP B and/or GROUP C claims, AND you want the claims administrator to try to

If you are submitting any GROUP B and/or GROUP C claims, AND you want the claims administrator

get supporting documentation for you from your health care provider(s) - you must fill out one of these forms

to try to get supporting documentation for you from your health care provider(s) - you must fill out one

for each provider you would like contacted. You can download more forms at ,

of these forms for each provider you would like contacted. You can download more forms

or photocopy this form before filling it out. Mail the completed form(s) to Health Net Class Action Litigation,

at , or photocopy this form before filling it out. Mail the completed

c/o Berdon Claims Administration LLC, at P.O. Box 9007, Jericho, NY 11753-8917, postmarked on or before

form(s) to Berdon Claims Administration LLC, at P.O. Box 9007, Jericho, NY 11753-8917,

April 10, 2015. Questions? Call Berdon at 1-800-766-3330.

postmarked on or before Month 00, 0000. Questions? Call Berdon at 1-800-766-3330.

Authorization to Release Health Care Billing Information

Patient Name:__________________________________

I, ________________________________________, give permission to the Out-Of-Network Provider listed below, to release

health care billing information to Berdon Claims Administration LLC, P.O. Box 9007, Jericho, NY 11753-8917, for services

I received on:

Date of Service: ______/______/_______

Date of Service: _____/______/________

I understand that I am granting this authorization under the Health Insurance Portability and Accountability Act (HIPAA). I

understand that I have the right to revoke this Authorization, in writing, at any time by so notifying Berdon. Such revocation

will not affect actions taken by Berdon prior to the date it receives the written revocation.

Signature: _______________________________

Date: _______________________

Print Name: __________________________________ Home Address: __________________________________________

City: ___________________________________ State: ___________ Zip : ________________________

Day Time Telephone Number: (

) _____________________ Email Address: __________________________________

Reference Number that appears on your Blue Sheet: ______________

If signed by patient’s authorized representative, describe the representative’s authority (check one):

________ Patient is a minor; I am the patient’s parent

________ Patient is a minor: I am the patient’s guardian

________ Patient is deceased. I am the patient’s surviving spouse or I am the executor or administrator of the patient’s estate.

________ Other (please describe): ________________________________________________________

PROVIDER INFORMATION

Provider Name: _______________________________________________________________________

Provider Address: _____________________________________________________________________

Provider City: ______________________________ State: ___________ Zip: _____________________

Provider Phone Number: (

) ____________________ Provider Fax Number: (

) _______________________

Hipaa Form Authorization To Release Health Care Billing Information